198204701-3-29-2021-28-AS-CYEE-C4H4DH-20210630190047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204701
Report Date: 03/29/2021
Date Signed: 03/29/2021 05:10:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210323105312

FACILITY NAME:	BROOKDALE WALNUT		FACILITY NUMBER:	198204701
ADMINISTRATOR:	MATSUMOTO, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	19850 E COLIMA RD		TELEPHONE:	(909) 595-5030
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	120	CENSUS: 64	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Christina Matsumoto		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility elevator is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Christina Matsumoto, the facility administrator.

LPA Spencer conducted telephone interviews with the administrator, Staff #1-2, and Residents #1-6. A video call was conducted consisting of a review of the physical plant including the elevators and Evac chair. The LPA received copies of the staff roster, resident roster, elevator part purchase order, contact information for Amtech Elevator Services, and letter to residents informing them of the out of service elevator. This was sent to the LPA’s attention via email on 3/29/21. During the course of the investigation, LPA also interviewed a staff member at Amtech Elevator Services.

***See LIC9099C for continuation of narrative.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210323105312

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE WALNUT	FACILITY NUMBER: 198204701
	VISIT DATE: 03/29/2021

NARRATIVE

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The investigation revealed the following:

Facility elevator is in disrepair
During the virtual inspection, LPA Spencer observed that the facility's elevator was not working. It was blocked off by a divider and there was a sign posted stating that the elevator was out of order. LPA received an SIR dated 1/29/21 reporting that the elevator was out of service due to a bad cylinder. The estimated date of repair was 3 weeks. During interviews, the administrator stated that the elevator has been out of order since 1/29/21 and has not been fixed yet because the proposal to order the cylinder had to approved by the corporate office and that the part was ordered on 2/18/21. A review of the purchase order confirmed that the part was ordered on 2/18/21. The administrator stated that the part should arrive at the facility by the end of the week and the estimated time of completion is approximately 2 weeks from today. The administrator stated that resident meals are being delivered to their door and that activities are provided on both floors. The administrator stated that if residents have doctor appointments or need to go downstairs, the facility has Evac chairs, stair climbers, or can use a 2-person assist to help the resident down. During the inspection, LPA Spencer observed the Evac chairs that are available for non-ambulatory residents. 6 residents who live on the 2nd floor were interviewed. All 6 residents stated that the elevator is in disrepair and that it has caused inconvenience due to how long it has been in disrepair. 2 staff were interviewed and confirmed that the elevator has not been working since the end of January. S1 stated that the cylinder replacement has to be custom-made and that's why it couldn't be fixed right away. An interview with a staff member at Amtech Elevator Services revealed that the proposal was given to Brookdale Walnut on 1/29/21 but that there was a delay in approval due to additional information being requested. The staff member stated that the part was received today 3/29/21 and they are scheduled to install on 3/30/21 with the project completed in 2.5 days. The elevator will be operational pending state inspection.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210323105312

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE WALNUT	FACILITY NUMBER: 198204701
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/29/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that she will send proof of completion of elevator repair and date of state inspection to CCL by 4/9/21.
	8 9 10 11 12 13 14	Based on observation, interview, and record review, the licensee did not ensure that the facility's elevator was repaired in a reasonable amount of time. This poses a potential safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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